Provider Demographics
NPI:1992873798
Name:CALDWELL COMPOUNDING PHARMACY INC
Entity type:Organization
Organization Name:CALDWELL COMPOUNDING PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES PIC
Authorized Official - Prefix:
Authorized Official - First Name:ERCIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:620-845-6916
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:KS
Mailing Address - Zip Code:67022-0032
Mailing Address - Country:US
Mailing Address - Phone:620-845-6916
Mailing Address - Fax:620-845-6961
Practice Address - Street 1:7 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:KS
Practice Address - Zip Code:67022-1529
Practice Address - Country:US
Practice Address - Phone:620-845-6916
Practice Address - Fax:620-845-6961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
KS2081013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100437110AMedicaid
2031598OtherPK
0840540001Medicare NSC